My new book, "Health, Medicine and Justice: Designing a fair and equitable healthcare system", is out and and widely available!
Medicine and Social Justice will have periodic postings of my comments on issues related to, well, Medicine, and Social Justice, and Medicine and Social Justice. It will also look at Health, Workforce, health systems, and some national and global priorities

Sunday, July 27, 2014

I am finished writing the book, as yet untitled, that I have
been working on during my sabbatical, which accounts for the sparse number of
blog posts. This is not to say that the book is anywhere near ready to be
published; I am sure it will need more revisions.

However, it does mean that I am likely to be posting to the
blog more frequently, as I find things that inspire me to write.

Thanks for your patience!
Josh

The Affordable Care Act (ACA) has been law since 2010, and
was supposed to have been fully implemented this year in 2014, although as is
clear many of its provisions have not yet been. The most important has been the
failure of about half our states to implement the expansion of Medicaid, which
was the mechanism through which the law intended to cover all those poor
(incomes under 133% of the federal poverty level) who are currently ineligible
for Medicaid (most of those now receiving it are poor children and their
mothers, although the majority of dollars are spent on nursing home care). This
is legal as a result of the Supreme Court decision that was important because
it made the rest of the law legal; this is, I think, of faint solace to those poor
people who live in my state of Kansas and the others who have failed to expand
Medicaid despite the fact that the federal government would have paid 100% of the
cost for 4 years, then 90%.

The newest court actions that affect ACA are two Court of
Appeals decisions which say, basically, opposite things about the subsidies
that support the premiums of people making above 133% of poverty but less than
allows them to pay the full amount.[1]
One court decided that people living in states that ran their own exchanges
were eligible for the subsidies, but that those who were in
federally-administered exchanges were not. The other appeals court decided that
both were. Of course, those states that have federally-administered exchanges
are those with governors and legislatures who oppose ACA completely; they
include all those who did not expand Medicaid plus many more (about 36
altogether). This suggests some political agenda; the interpretation of
Congressional intent rather than parsing the words, has historically been the
basis for such court decisions. It also will mean that the cases will go to the
Supreme Court, sometimes known as SCOTUS, but now appropriately called COCUHL
(Court of Citizens United and Hobby Lobby), where it will be amazing if a
conscious, careful, legal approach supersedes politics. The decision to
basically gut the Hobby Lobby decisions one remaining protection only a day
after it was announced bodes ill. The Republicans in Congress have decided to
sue President Obama for not implementing portions of the ACA, which, as Timothy
Egan of the NY Times points out, “…they have tried to repeal more than 50
times.”[2]

What has the Republicans so flustered that they have taken
to self-contradictory actions is, in fact, the success of the ACA at achieving
many of its goals. These are summarized in another NY Times op-ed, by Paul
Krugman, titled “Obamacare fails to fail”.[3]
There has been a huge surge in enrollment, and while indeed some people are
paying more (largely healthy young people who are low risk for high-cost
illness, thus previously had lower premiums), most people (including 74% of
Republicans) are happy with their current premiums. In addition to the early
wins (preventing insurance companies from not covering those with pre-existing
conditions, allowing young people to stay on their parents’ insurance until
they are 26), we now add over 6 million people who are newly covered, and can
access health care. Despite decisions such as Hobby Lobby, most women will now
get contraceptive coverage without a copayment. It is a good thing. This is why
opponents (mainly ideological) are trying any trick that they can to limit its
effectiveness, including the two biggest addressed above—not expanding Medicare
and trying to block subsidies for those on the federal exchanges. That is to
say, trying to limit health insurance coverage to our less-affluent citizens.

But ACA, even if it came through all the court decisions unscathed,
is not a solution. It doesn’t cover those who are not citizens, even though
they live here. It is a gift to insurance companies, who still get to charge
high rates and make enormous profits, but now have the federal government
paying the premiums. Therefore, it will not really save cost. Don’t get me
wrong – I am not advocating that we provide less of the health care people need
to save money (although I do advocating not providing “health care” that will
not help or even harm people just because someone can make money on it). I am saying
that the huge profits guaranteed for insurers, and other components of our system
who make profit, make it excessively costly. It costs us way more per capita, for poorer health outcomes,
than do the healthcare systems of other developed countries. The latest edition
of “Mirror, Mirror on the Wall”, published in 2014 by the Commonwealth Fund
demonstrates this clearly; in comparing 11 wealthy countries the US ranks #11
overall, and #11 in 3 of the 5 areas examined (Efficiency, Equity), and Healthy
Lives), #5 in Quality, and #9 in Access. It achieves this less-than-mediocre
performance by spending (2011) $8508 per capita, while the other 10 countries
spent from $3182 (New Zealand) to $5669 (Norway).[4]

The problem is not that our system is not working, but that
it is. Paul Batalden is famous for saying “every system is perfectly designed
to get the results that it gets”, and ours is. The results that we get are relatively
poor health outcomes on a population basis, large numbers of people excluded
from health care coverage (even after ACA), many people getting unnecessary
care because someone can make a profit on it, and the bizarre concept that
there are not only people who are
preferable to provide care for (because of their wealth or insurance status)
but even diseases that it is
preferable to provide care for (because the profit margin is better). Our
system is not designed for people’s health; it is designed so that some
(providers, insurers, drug companies, etc.) can make profit. It gets the
results it is designed to get.

But that is unacceptable. We need a health system designed
to maximize the health of our people. All our people. And we need it yesterday.

[4] Karen
Davis, Kristof Stremikis, David Squires, and Cathy Schoen, Mirror, Mirror on the Wall: How the Performance of the U.S. Health Care
System Compares Internationally, 2014 Update, The Commonwealth Fund, June
2014. http://www.commonwealthfund.org/publications/fund-reports/2014/jun/mirror-mirror

This examination is not to be
confused with the Pap smear screening test for
cervical cancer (although it regularly is). The Pap smear involves obtaining cells for cytological
examination from the cervix by means of a spatula and/or small brush. The Pap
smear is not perfect, but it is probably the best of the cancer screening tests
available to us; the US Preventive Services Task Force (USPSTF) recommends them
in women 21-65 years of age every 3 years. The pelvic exam, the part where the
doctor puts her/his hands inside a woman and feels around, is often done in
conjunction with the collection of the Pap, thus the basis for the confusion
among many women. It is not recommended by USPSTF at all, at any frequency[2],
but the American College of Obstetricians and Gynecologists (ACOG) recommends
it on an annual basis.

I have long been a teacher of
family medicine, and for many years have told my students and residents that there
was no indication for this examination, at any frequency, for screening. I do
this despite the fact that I know they are taught to do so on their OB-Gyn
clerkships and rotations, and not because I believe I am more experienced in
providing women’s reproductive health care than are the OB-Gyns. I can,
however, read the evidence. By definition screening occurs in asymptomatic
people; should a woman present with symptoms referable to the pelvic region
(for example, pain, bleeding or discharge) the examination may be indicated.
However, in the absence of symptoms it is a screening test, and should not be
done because there is nothing that it can screen for. Years ago, an argument
for doing it was screening for ovarian cancer, but many studies have
demonstrated that it is not effective for this purpose, because by the time an
ovarian cancer can be felt by the examiner, it is very far gone. These are
essentially the same reasons that USPSTF
and ACP recommend against it.

And, yet, ACOG, as noted, continues
to recommend it (”Annual pelvic examination of patients 21 years of age or
older is recommended by the College.”). The Times editorial notes that

…the gynecologists group argues that the
“clinical experiences” of gynecologists, while not “evidence-based,”
demonstrate that annual pelvic exams are useful in detecting problems like
incontinence and sexual dysfunction and in establishing a dialogue with
patients about a wide range of health issues.

This defense ranges from the
indefensible (that it is not evidence based) to the absurd (that it is the way
to find problems like incontinence and sexual dysfunction). If a woman has
incontinence or sexual dysfunction, she knows it and the way to discover it is
not by a pelvic exam, but by asking her. Clearly, the same is true of “establishing a dialogue with patients
about a wide range of health issues.” I strongly doubt that most women would
feel that having the doctor put his/her hands inside her vagina is the best way
to open such a dialogue!

Why, then, would ACOG continue to recommend it? Long ago, when I was in
medical school and residency, almost all OB-Gyns were men, and lack of empathy
could be a possibility, but this is far from the case now or in recent decades.
There is also the fact that such an examination, as a procedure, is reimbursed
at a much higher rate than simply talking to a patient. This is true also for
family physicians and other primary care providers (such as general internists,
which explains the ACP’s interest in the issue), but for OB-Gyns it is a much
greater percentage of their practice and thus their income. It is hard to break
with tradition, to change the way that you have always been taught, and it is
probably harder when there is a concrete disincentive (loss of income) for
changing.

But women, and all people, need to be able to trust that their doctors are
recommending and doing procedures, particularly invasive and uncomfortable
procedures like the pelvic examination, only when they are indicated by the
evidence. They need to have confidence that those physicians are not motivated,
consciously or not, by a conflict of interest (e.g., financial gain). One step
is for physicians to honestly look at the evidence, and avoid prioritizing
their anecdotal experience over that evidence.

More profoundly, however, our society, our health care system, needs to
eliminate perverse incentives for doing “more” even when it is not indicated,
still less when it is also unpleasant for the patient (like a pelvic exam), and
least of all when it is also dangerous (as other procedures are). Physicians should
be paid for maintaining and increasing the health of their patients, not for “doing
things”. If talking to the patient about “a wide range of health issues”,
including but not limited to incontinence and sexual dysfunction, is the right
way to find out about these problems, and if it takes a long time, then this is
what needs to be reimbursed, not a procedure.

We are currently a long way from this sort of reimbursement, for spending
the time needed to provide the best health care for a person. It is good that
ACP has added its voice to recommending against screening pelvic examinations,
but it is unsurprising that doctors do what they are paid to do. We need system
change.

[1]Qaseem A, et al, “Screening Pelvic Examination in Adult Women: A Clinical
Practice Guideline From the American College of Physicians”, Annals of Internal Medicine 2014;161(1):67-72.
doi:10.7326/M14-0701.